Assessment of Ventilation Using Adult and Pediatric Manual Resuscitators in a Simulated Adult Patient

BACKGROUND

The bag-valve-mask (BVM) or manual resuscitator bag is used as a first-line technique to ventilate patients with respiratory failure. Volume-restricted manual resuscitator bags (eg, pediatric bags) have been suggested to minimize overventilation and associated complications. There are studies that both support and caution against the use of a pediatric resuscitator bag to ventilate an adult patient. In this study, we evaluated the ability of pre-hospital clinicians to adequately ventilate an adult manikin with both an adult- and pediatric-size manual resuscitator bag without the assistance of an advanced airway or airway adjunct device.

METHODS

This study was conducted at an international conference in 2022. Conference attendees with pre-hospital health care experience were recruited to ventilate an adult manikin using a BVM for 1 min with both an adult and pediatric resuscitator bag, without the use of adjunct airway devices, while 6 ventilatory variables were collected or calculated: tidal volume (VT), breathing frequency, adequate breaths (VT > 150 mL), proportion of adequate breaths, peak inspiratory pressure (PIP), and estimated alveolar ventilation (EAV).

RESULTS

A total of 208 participants completed the study. Ventilation with the adult-sized BVM delivered an average VT of 290.4 mL compared to 197.1 mL (P < .001) when using the pediatric BVM. PIP with the adult BVM was higher than with the pediatric BVM (10.6 cm H2O vs 8.6 cm H2O, P < .001). The median EAV with the adult bag (1,138.1 [interquartile range [IQR] 194.0-2,869.9] mL/min) was markedly greater than with the pediatric BVM (67.7 [IQR 0-467.3] mL/min, P < .001).

CONCLUSIONS

Both pediatric- and adult-sized BVM provided lower ventilation volumes than those recommended by professional guidelines for an adult. Ventilation with the pediatric BVM was significantly worse than with the adult bag when ventilating a simulated adult subject.

Association of race and socioeconomic status with the rate of bystander-initiated CPR in Memphis

STUDY OBJECTIVE

This study evaluated the association of race and socioeconomic status with the rate of bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest in Memphis, TN and compared it to 25 years prior.

METHODS

This was a retrospective cross-sectional study of out-of-hospital cardiac arrest events in the Memphis area from 2012-2018. The primary outcome of interest was the provision of bystander CPR. Socioeconomic status was estimated using the Economic Hardship Index model. A generalized linear mixed model analysis was conducted.

RESULTS

The overall rate of bystander CPR was 33.6%. White patients were more likely to receive bystander CPR compared to black patients (44.0% vs 29.8%, adjusted odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.40-2.05). Patients in areas of increased economic hardship were less likely to receive bystander CPR (OR = 0.713, 95% CI = 0.569-0.894). Overall bystander CPR rate increased by 18.7% over the past 25 years.

CONCLUSION

Despite significant increases in bystander CPR compared to 25 years ago, black individuals are still less likely to receive bystander CPR than white individuals in Memphis. Both race and socioeconomic status were independent predictors of the rate of bystander CPR. By using neighborhood demographics and the Economic Hardship Index, communities with low overall bystander CPR rates, such as Memphis, can focus limited resources on areas of greatest need and potential effectiveness.

Endothelial cell regulation of nitric oxide production during hypoxia in coronary microvessels and epicardial arteries

Nitric oxide (NO) synthesized by endothelial cell nitric oxide synthase (eNOS) elicits vasodilation of resistance-sized coronary microvessels. Since coronary blood flow increases during hypoxia, we tested the hypotheses that: (1) hypoxia results in increased blood flow through increased NO production mediated by the upregulation of both eNOS mRNA and protein and (2) the regulation of NO production in response to hypoxia differs in microvascular endothelial cells and nonresistance, epicardial endothelial cells. Monocultures of vascular endothelium from resistance (approximately 100 micro) and nonresistance epicardial arteries were established and characterized. Nitric oxide was quantitated using a chemiluminescence method. Hypoxia (pO(2) = 10 mmHg) significantly increased NO production in both cell lines, with less NO produced in microvascular endothelium. Western blots demonstrated that hypoxia caused a time-dependent increase in eNOS protein in both lines, with an average 2.5-fold increase in nonresistance, epicardial endothelial cells compared to an average 1.7-fold increase in protein from microvascular endothelium. Total mRNA recovery increased 2.4 +/- 0.6-fold within 30 min of hypoxia in nonresistance, epicardial endothelial cells with no increase in microvascular endothelial cells. Although hypoxia increased NO production in both populations of endothelial cells, the increase in NO production and eNOS protein in microvascular endothelium was less compared to nonresistance, epicardial endothelial cells. Furthermore, there was no significant upregulation of total mRNA for eNOS in microvascular endothelium. The data indicate that increased NO production in microvascular endothelium during hypoxia may be through translational or posttranslational modifications of the enzyme, whereas transcriptional upregulation may account for the increased NO production in nonresistance, epicardial endothelial cells. Oxygen-sensitive response mechanisms that modulate NO production may be different in endothelium from different coronary artery vascular beds.

Hydrophobicity and subunit interactions of rod outer segment proteins investigated using Triton X-114 phase partitioning

Triton X-114 phase partitioning, a procedure used for purifying integral membrane proteins, was used to study protein components of the mammalian visual transduction cascade. An integral membrane protein, rhodopsin, and two isoprenylated protein complexes, cyclic GMP phosphodiesterase and Gt beta gamma, partitioned into the detergent-rich phase. Arrestin, a soluble protein, accumulated in the aqueous phase. Gt alpha distributed about equally between phases whether GDP (Gt alpha.GDP) or GTP (Gt alpha.GTP) was bound. Gt beta gamma increased recovery of Gt alpha.GDP but not Gt alpha.GTP in the detergent phase. Trypsin-treated Gt alpha, which lacks the fatty acylated amino-terminal 2-kDa region, accumulated to a greater extent in the aqueous phase than did intact Gt alpha. Trypsinized cGMP phosphodiesterase, which lacks the isoprenyl group, partitioned into the aqueous phase. A carboxyl-terminal truncated mutant (Val-331 stop) of Gt alpha accumulated more in the aqueous phase then did recombinant full-length Gt alpha, supporting the role of the carboxyl terminus in increasing its hydrophobicity. N-Myristoylated recombinant Go alpha was more hydrophobic than recombinant Go alpha without myristate. ADP-ribosylation of Gt alpha catalyzed by NAD:arginine ADP-ribosyltransferase, but not by pertussis toxin, increased hydrophilicity. Triton X-114 phase partitioning can thus semiquantify the hydrophobic nature of proteins and protein domains. It may aid in evaluating changes associated with post-translational protein modification and protein-protein interactions in a defined system.

Involvement of N-myristoylation in monoclonal antibody recognition sites on chimeric G protein alpha subunits

Monoclonal antibody, LAS-2, directed against the alpha subunit of transducin (Gt alpha), inhibited Gt beta gamma-dependent, pertussis toxin-catalyzed ADP ribosylation of Gt alpha and was specific for Gt alpha. Immunoblotting studies on proteolytic fragments of Gt alpha were consistent with an amino-terminal epitope. To define the antibody recognition site, recombinant Gt alpha was synthesized in Escherichia coli cotransfected with or without yeast N-myristoyl-transferase. Amino-terminal fatty acylation of Gt alpha, verified by use of radiolabeled fatty acid, was required for immunoreactivity. LAS-2 did not react with a chimeric protein consisting of residues 1-9 of Gt alpha and the remainder Go alpha, regardless of its myristoylation. Immunoreactivity was observed when amino acids 1-17 of Gt alpha were present in a Go alpha chimera and the protein was amino-terminally myristoylated; there was no reactivity without myristoylation. It appears that the LAS-2 epitope requires both Gt alpha-specific sequence in amino acids 10-17 and a fatty acyl group in proximity to these residues. These results are consistent with the hypothesis that the myristoyl group is essential for protein structure; conceivably it "folds back" on and stabilizes the amino-terminal structure of Gt alpha as opposed to protruding from an amino-terminal alpha-helix and serving as an amino-terminal membrane anchor.

Effect of temperature and host factors on the activities of pertussis toxin and Bordetella adenylate cyclase

Pertussis toxin and adenylate cyclase toxin both contribute to the pathogenesis of whooping cough. Production of these proteins is controlled by the bvg locus, which is inactive at 25 degrees C, but at 37 degrees C produces a Vir+ phenotype. In view of the temperature dependence of virulence factor synthesis, the effects of temperature and host factors on their action were examined. The NAD glycohydrolase activity of the S1 subunit of pertussis toxin was enhanced by CHAPS, a zwitterionic detergent, with a temperature optimum of approximately 35 degrees C. Similar temperature optima for the ADP-ribosylation by pertussis toxin of transducin and recombinant Go alpha were observed. Since the temperature--activity relationship of S1 differed from that of S1 in activated holotoxin, and since S1 in activated holotoxin was more stable at 42 degrees C than was S1, it appears that S1 associated with the B oligomer components may, in fact, be an active species. Bordetella pertussis adenylate cyclase is activated by a host factor, calmodulin. In the absence of calmodulin, the temperature optimum for enzymatic activity was approximately 25 degrees C, whereas in its presence it was approximately 35 degrees C. Thus, the temperature optima for pertussis and adenylate cyclase toxins, virulence factors whose production is increased through the bvg locus at physiological temperatures, are either at or near these temperatures when stimulated by host factors.

Role of chemotactic factor inactivator in modulating alveolar macrophage-derived neutrophil chemotactic activity

The stimulated alveolar macrophage is a potent source of neutrophil chemotactic activity. The release of this chemotactic activity can be inhibited by pretreating alveolar macrophages with anti-C5 antibody. We hypothesized that C5a, a fragment cleaved from C5 when C5 is activated, might activate the alveolar macrophage to release neutrophil chemotactic activity and that chemotactic factor inactivator, a serum inhibitor of C5a, could decrease this release. Activated complement components including C5a were found to stimulate guinea pig macrophages to release chemotactic activity into their culture supernatants at levels that were significantly higher than the chemotactic activity of C5a alone (P less than 0.001). Chemotactic factor inactivator was found to cause a marked reduction in the chemotactic activity released by macrophages stimulated with phagocytic and nonphagocytic stimuli (P less than 0.001, all comparisons). These data indicate that C5a can stimulate alveolar macrophages to release chemotactic activity in vitro, and that chemotactic factor inactivator may play a role in modulating this process.